If ‘The Body Keeps the Score’: Mapping the Dissociated Body in Trauma Narrative, Intervention, and Theory

ABSTRACT

Psychotherapy, a central social space for remembering, has from its inception centred upon the healing and integrative power of putting experience into words and narrative forms of expression. However, those who have experienced traumatic events often lack a coherent memory for or understanding about the trauma they have undergone; they may be haunted by inchoate bodily sensations and ‘memories’ that have not been fully integrated and cannot be put into language. Such splits in experience – between body and mind – can provide a means to understand the way we conceptualize memory, consciousness, and body-mind. This paper describes an intervention that seeks to help people to make the experiences of the body more intelligible.

Keywords:

psychological

trauma, body (somatic), visuality, psychological

intervention

As a psychiatrist with a practice in the psychotherapy of people who have experienced psychological trauma, I draw on the burgeoning ﬁeld of trauma studies, reaching back to Charcot, Janet, and Freud, to provide a wealth of clinical guidance. However, individual patients often prompt inno- vations or attempt to fashion new means to accommodate material that they are attempting to work through. Work with a patient whom I will call Mr M, a man who was experiencing the aftermath of a traumatic loss and personal injury, for example, necessitated an exploration of bodily symptoms that he did not easily speak, nor could he easily account for them in his terse and evasive account of the traumatic event that he had experienced. In order to work with Mr M’s bodily symptoms, such as pain, which were evident and yet were difﬁcult to access in the therapy, I introduced a technique known as body mapping, described in greater detail below. Reﬂecting on this work with Mr M, I see that such innovations that arise from clinical impasses can also illuminate underdeveloped areas within psychiatry. Why, in other words, within the context of psychotherapy, was it so difﬁcult to ﬁnd the words for Mr M’s bodily symptoms? For a number of complex historical and philosophical reasons, higher-order mental processes such as language and cognition have historically been

privileged over emotion and somatic experience in understanding the workings of ‘mind’ and consciousness (Damasio 188). Cognitive processes, accessed through language in psychotherapy, have also similarly been the targets of traditional psychotherapeutic interventions, with a ‘traditional distinction between the lower emotional appetites and the higher functions of rational control’ (Leys 86), and an emphasis on recollection and narra- tion from Freud’s model of the ‘talking cure’ onward (110), to the exclusion of attention to the body, which was ‘left out of [this] “talking cure”’ (Ogden, Minton, and Pain xxvii). That is not to say that psychiatry ignores the body. Psychiatry has its arsenal of physical therapies such as pharmacological interventions, but I would argue that it imagines these interventions as acting directly on the brain, with any impact on the body understood pri- marily within the purview of ‘side effects’ rather than as desired treatment outcomes. This understanding has been only further entrenched by advances in neuroimaging that enable research scientists to ‘see’ treatment effects directly in the altered architecture and neurochemical functioning of the nervous system and its structures. However, more recently, challenges to this dualistic conception of body and mind have come at all levels of inquiry, with new insights yielded about the intimate and inseparable interconnectivity of the mind-body. Antonio Damasio’s work in the neurobiology of consciousness, for example, demonstrates the necessity of somatic input for the experience of self and for a conscious encountering of the world. The work of phenomenologists such as Merleau-Ponty has prompted insights into the embodied experience of living with ‘mental’ illnesses and has simi- larly challenged artiﬁcial distinctions between the mind and body, arguing instead for ‘embodied consciousness’ (Fuchs). Recent developments in psychotherapy have also led to a widening under- standing of the importance of attending to the body. Nowhere is this more evident than in the psychotherapeutic treatment of psychological trauma. Pat Ogden and her colleagues attempt to redress the fact that ‘working directly with the client’s embodied experience [has been] largely viewed as peripheral to traditional therapeutic formulation, treatment plan, and inter- ventions.’ Their sensorimotor psychotherapy ‘approaches the body as central in the therapeutic ﬁeld of awareness’ (xxvii). This paper also describes an intervention that brings the body into focus within psychotherapy, and, along with other such somatic interventions, prompts a reorientation toward the body and away from a false mind-body dichotomy.

CASE

OF

MR

M

Mr M is actually a composite of several clinical cases of individuals who had experienced traumatic loss secondary to being the victim of a crime. The use of a composite allows for the protection of conﬁdentiality in a way that

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changing the superﬁcial details of a case cannot. The use of the clinical body maps in this paper are used with explicit permission. 1Mr M was an unmar- ried forty-two-year-old man who worked as a legal aid lawyer. Though not in a romantic relationship, he had a strong group of friends. He had a caregiving relationship with his elderly mother, who frequently required hospitaliz- ations for medical illness; he described her as ‘harsh,’ ‘occasionally cruel,’ and neglectful during his childhood. Mr M was presented to me because of nightmares and upsetting memories related to witnessing the murder of his girlfriend and being badly injured himself thirteen years earlier. He linked his symptoms to exposure to a news story just prior to the anniversary of her death. It became evident early on in our treatment that he was also experiencing worsening physical pain, including generalized body aches, lower back pain, and knee pain to the point where he had begun limping and required a cane. He was bafﬂed by the degree to which he was experien- cing this ‘setback’ after so many years and was particularly surprised by the degree of physical pain that he was experiencing; he expressed uncertainty about whether it was directly linked to the traumatic incident. At other times, he wondered why he had not been more affected by the traumatic loss, why he was ‘not a basket case.’ In addition to a longstanding history of somatic symptoms (physical discomforts), he had a history of alexithymia, or a difﬁculty describing his emotions and internal states. He placed a great deal of emphasis on his ability to present himself as cheerful and to remain independent. He was determined not to ‘wallow’ or be a ‘downer,’ but was also quite ‘sensitive’ and wanted to keep his deceased girlfriend’s ‘memory alive.’ Initially, Mr M gave a very fragmented account of the trau- matic loss of his girlfriend, and of his own experience of being physically assaulted during the trauma. He would refer to certain aspects only tangen- tially and would not use his girlfriend’s name. He spoke in a very pressured way that I could not easily interrupt or regulate. Several times, despite my attempts to slow his accounts, he dissociated (i.e., became unaware of his present surroundings) in my ofﬁce; I could see him physically responding to blows that he was reliving from the time of the trauma, and he was crying.

TRAUMA ,

MEMORY ,

AND

NARRATIVE

Psychological trauma has a complex nosological and political history, well summarized by many, including Judith Herman. Post-traumatic stress disorder (PTSD), as a diagnostic entity, was introduced into the Diagnostic and Statistical Manual of the American Psychological Association (DSM) in 1980, and captures many elements of post- traumatic reactions. PTSD, according to the current DSM classiﬁcation,

1 The use of composites when presenting clinical material is an increasingly common strategy in ﬁelds such as bioethics, narrative medicine, and psychiatry (for example, see Charon).

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results from exposure to an event in which one believes that one will die or be bodily injured, or that someone else will die or be physically injured, to which one responds emotionally with terror or horror. 2Exposure to such an event can in some individuals manifest as the symptoms out- lined in the DSM (463): symptoms of re-experiencing the event (in the form of nightmares, intrusive memories, or ﬂashbacks); hyper-arousal (disrupted sleep, irritability, being easily startled, for example); and through avoidance (of places associated with the trauma, of talking about it, of being close to others, etc.). These symptoms may be usefully categorized as falling into two oscillating clusters: hyper-arousal, the ‘too much’ symptoms such as re-experiencing; and hypo-arousal, or the ‘too little’ symptoms of avoidance (Horowitz, van der Kolk, and van der Hart). In an effort to mute the overwhelming affective and bodily states associated with hyper-arousal, overcompensation may result, leading to constriction, numbing, and shutting down, as an attempt to ‘forget’ the traumatic event on all levels of functioning. PTSD, therefore, has also been called a ‘disease of time’ by Allan Young (7), because the subjective experience is one of the past invading the present; when attempts to forget are inadequate, ‘re-experiencing’ breaks through as a form of ‘remembering’ in the present, which in severe cases can make the traumatic time of the past be literally experienced as the present. The memory systems have long been implicated in responses to trauma. In 1889, Pierre Janet hypothesized that intense emotional or trau- matic experience interferes with the integration of events into existing memory schemas, such that traumatic memories can be dissociated from consciousness and stored instead as visceral sensations and visual images. 3Similarly, Breuer and Freud, in Studies in Hysteria, which

2 The deﬁnition of post-traumatic stress disorder offered in the DSM obviously offers a limited, psychiatric deﬁnition of what is considered to be a ‘trauma.’ Older versions of the DSM speciﬁed that a traumatic event is outside the realm of usual experience. That criterion has since been removed, acknowledging the very subjective and hetero- geneous nature of human responses to traumatic events. It reminds us, however, that the DSM is an ideological document, in that it is shaped not only by scientiﬁc evidence but also by social and political mores.

3 Ruth Leys provides a provocative overview of how Janet’s work has been appropriated by contemporary trauma theorists such as Judith Herman, Bessel van der Kolk, and Cathy Carruth (105). She shows, for example, that Herman used Janet’s distinction between traumatic memory (‘which merely and unconsciously repeats the past’) and bio- graphical memory (‘which narrates the past as past’), but chose to focus on Janet’s empha- sis on the importance of ‘remembering’ trauma, while ignoring the strain in his work that also acknowledged the importance of forgetting (106). Such selective appropriation highlights the fact that our notions of ‘trauma’ are embedded in social and ideological contexts within which theory has great implications for how we approach the lived, political, and interpersonal dimensions of trauma.

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included Breuer’s formative case study of Anna O, concurred that mem- ories associated with intolerable affects could be repressed or ‘forgotten.’ ‘The hysteric suffers mostly from reminiscences’ (4), though the afﬂicted person may seem to have forgotten the originary experience (6), having the tendency to split or dissociate it from conscious awareness (8). There are many contemporary schemas for representing memory; the storage or stage model of memory, originating with Richard Atkinson and Richard Shiffrin, is one of the most familiar (cf., Bower), which conceptualizes information as moving from shorter- to longer-term storage in memory, depending on the depth of processing or elaboration (by related brain structures) of the information. Information passes through different stages of processing, from working memory or short- term memory and then to longer-term memory as it becomes increasingly consolidated. Long-term memory is in theory capable of storing larger quantities of information for later recall, and for longer durations of time. 4Long-term memory is often further subdivided into declarative, semantic, or explicit memory – the kind of memory that underwrites autobiographical memory – and implicit or procedural memory for habit- ual actions, like riding a bike (Anderson). In the normal laying down of declarative memory, sensory inputs are processed in the thalamus and other structures of the limbic system, the ‘emotion’ centre of the brain that mediates emotion, memory, and learning. Proper functioning of the hippocampus (an important limbic structure for the consolidation of declarative memory) is necessary for semantic or declarative memory to develop from sensory inputs (26). In contemporary psychiatry, the study of memory disruption in PTSD was reinvigorated by Kolb in 1987, who proposed that excessive stimu- lation of the central nervous system, particularly of the memory structures such as the hippocampus, may result in permanent neuronal changes that have a deleterious effect on learning and memory. Unresolved memories of a traumatic event are often described as highly vivid and sensory, more emotionally intense, but less clear and coherent, more fragmented, less likely to occur in a meaningful temporal or causal sequence, and less under conscious control, and they tend to intrude and are difﬁcult to dispel (Foa, Molnar, and Cashman). This is in contrast to autobiographical memories and resolved traumatic memories that are an integrated part of identity, which may be recalled voluntarily, with the capacity of the

4 It is important to remember that this and other models of memory are essentially working metaphors that guide conceptualization and research into memory. Even if we think of memory as proceeding through several stages of processing from one storage container to another – from shorter- to longer-term storage containers of memory, for example – this is not to be taken as concrete storage areas of the brain. The Atkinson-Shiffrin multi-store model has, for example, been criticized for being too simplistic and linear.

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remembering person to shift attention away from the memory and to maintain simultaneous awareness of external reality. Bessel van der Kolk followed up on Kolb’s insights in his seminal article, ‘The Body Keeps the Score,’ in which he postulated that ‘although memory is ordinarily an active and constructive process, in PTSD failure of declara- tive memory may lead to organization of the trauma on a somatosensory level’ (253). In other words, the biological underpinnings of the traumatic stress response, with associated hormonal and neurochemical assaults on memory structures such as the hippocampus, prevent the development of coherent autobiographical memories of the traumatic event. The event is then recollected in a fragmented way as predominantly bodily or sensory ‘memory.’ For example, one may relive certain smells associated with the traumatic event (such as smoke in the case of a house ﬁre) or bodily sensations (such as a feeling of constriction around the neck in someone who has been strangled). Sometimes these symptoms can have an obvious indexical relationship to the traumatic event, such as in the above examples; at other times they bear no clear relationship to the event, and in either case can make people feel haunted by something out of their control or comprehension. In severe cases, such sensory and bodily reliving of traumatic events can be entirely dissociated from con- scious awareness and the person can be mentally ‘pulled back’ into the physical and sensory dimensions of the traumatic event. Each bodily or mental register of experience can be walled off from the other in conscious- ness. This dissociation, an often contested phenomenon in psychiatry, refers to a ‘disruption in the usual integrated functions of consciousness, memory, identity, or perception of the environment’ (DSM 519). Clinician researchers, in particular Pat Ogden in the development of sensorimotor psychotherapy, have acknowledged a debt to van der Kolk, and his recognition of the extent to which the body is disrupted in PTSD. Ogden and her colleagues draw on ‘neuroscience’ (ix) in sup- porting the development of their work with the body in psychotherapy. Van der Kolk, who in turn provides the foreword to Ogden’s book, cites neuroscientist Antonio Damasio, who also hails the importance of the body or ‘bottom-up’ processes in creating consciousness and other higher-order functions of the mind such as memory: ‘physical actions are creating the context for mental actions; bottom-up processes are affect- ing upper level processes’ (xix). However, instead of taking this accumu- lation of neuroscientiﬁc and clinical data as established fact, one should be reminded that it is an emerging and ongoing ﬁeld of scientiﬁc and psychological inquiry. Memory, from its psychological to its biological and its political dimensions, is one of the most contested areas of PTSD research. McNally, for example, provides a scathing critique of the way memory is conceptualized by researchers of PTSD. Heim and Nemeroff, in their review of the neurobiology of PTSD, do not even reference van

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der Kolk’s work. They do acknowledge that one of the most replicated ﬁnd- ings in people with PTSD is volume loss in the hippocampus, which is further correlated with severity of PTSD and memory impairment. Ruth Leys, in her history of the concept of trauma, is overtly critical of van der Kolk, ﬁnding that he invokes the weight of science and its ‘successful paradigms, technologies, and practices’ (258) to weld his scant ‘evidence’ into the appearance of a comprehensive theory. She ﬁnds that van der Kolk’s ideas of traumatic memory are essentially aligned with a political stance – ‘the necessity of attempting to tie the signs and symptoms of trauma as directly as possible to the precipitating event in order to prove that there is a direct link between the cause and its consequences’ (263). In order to prove such causality, which is important for the social and judi- cial response to people who have been exposed to traumatic events, she argues that van der Kolk and others have insisted on traumatic memory as having a kind of pristine literality, of being faithfully ‘etched’ on the mind (and body) rather than being a subjective representation of events. While I want to acknowledge the contested and unresolved nature of memory in this ﬁeld, the recognition of the importance of the body, as a site for registering and continuing to register traumatic experience, has been critical in my work with Mr M and with other clients. The hypoth- esis that PTSD represents a failure in memory formation, storage, and/or retrieval captures many dimensions of the post-traumatic response, from hypermnesia to amnesia and dissociation, each extreme also having concomitant states in the body. In Mr M’s case, the re-emergence of ﬂash- backs, nightmares, and worsening physical pain occurred immediately following exposure to a news story that reported an event similar to his traumatic experience, and just prior to the anniversary of his girlfriend’s death. My task, clinically, was to help Mr M understand these seemingly disparate mental and physical symptoms as manifestations of his unre- solved ‘memory’ of the traumatic events, in an effort to help him to inte- grate these fragments into a more ‘resolved’ memory, helping him move toward an integration of the past with the present, and of the mind with the body. Resolution of the traumatic or disrupted memory processes would be manifested as a more coherent, less fragmented memory, in which all aspects could be meaningfully integrated into a narrative account, an account that was under full control of consciousness, could be accessed and also put aside at will, and that formed a part of autobiographical memory (and thus identity) without being able to invade the present (and undermine identity). The importance of putting symptoms into words was evident in Breuer and Freud’s early theorizing about Breuer’s work with Bertha Pappenheim (Anna O). In the emergence of what was to become ‘the talking cure,’ Breuer encouraged his patient to ‘relate a story’ (19) or put her experiences, terrifying affects, and fantasies into words. Narrative has continued to be a

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cornerstone of psychological intervention in people with PTSD, perhaps because, in contrast to traumatic memory, narrative ordinarily necessitates a temporal sequencing and order. It is also, of course, interpersonal, through the act of telling the story to another. In order to communicate one’s experiences, and thereby gain the support of another, one has to make those experiences intelligible to the self. Many contemporary, evidence-based approaches to psychological trauma harness this power of narrative. Judith Cohen and colleagues’ development of trauma-focused cognitive behavioural therapy for children who have experienced psycho- logical trauma exempliﬁes this, with the therapy culminating in the cre- ation of a narrative of the traumatic event(s). Narrative exposure therapy, as developed by Schauer, Neuner, and Elbert, has been used with children and adults in a range of post-traumatic situations. Jonathan Morgan’s ‘memory boxes’ and ‘hero books,’ in which people recount traumatic events in the context of recounting their life ‘story,’ have been used in a number of African countries, initially in the context of children whose lives have been affected by HIV/AIDS. An important aspect of this work with narrative has been conceptualized as re-exposure to the traumatic event(s), but re-exposure with mastery in the context of psychotherapy (Foa, Molnar, and Cashman). Many of these psychotherapies that employ narrative-based approaches do implicitly harness the body. Cohen and her colleagues, for example, teach patients relaxation techniques to manage states of hyper-arousal, and also teach cognitive strategies for identifying and labelling affective states as they arise within the body. Psychotherapies that explicitly target the body, a relatively underutilized resource and under-theorized area in psychotherapy, are also emerging. One, in particular, is Pat Ogden’s (Ogden, Minton, and Pain) sensorimotor psychotherapy, which integrates somatic therapeutic approaches with cognitive-based work. Body mapping is another technique speciﬁcally aimed at the body, though it has not yet been applied to working with people with post-traumatic stress disorder. Body mapping was developed by artist Jane Solomon and psychologist Jonathan Morgan for working with people with HIV in sub-Saharan Africa. The therapeutic goal is to get individuals with HIV/AIDS to connect with their physical and emotional symptoms of HIV/AIDS as a vehicle for education, self-expression, and sharing. I was introduced to the technique of body mapping while I was doing work in Tanzania around the use of art for advocacy and education about HIV, and was impressed by its ability to get people to reﬂect on experiences of the body and integrate them into narrative. My own interest in narrative and relaxation in treating people with psychological trauma had led me to notice that some patients, particularly those with either alexithymia or dissociative features, were seldom able to progress in narrative-based therapies, often because they were completely

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overwhelmed at the prospect of working toward ‘telling their story’ and could easily become avoidant through missing therapy sessions. So I began adapting the technique of body mapping for use with such trauma- tized individuals in whom alexithymia and somatic complaints were dominant clinical presentations.

BODY

MAPPING

TECHNIQUE

A modiﬁcation to Morgan and Solomon’s approach is to teach basic grounding and relaxation exercises prior to initiating the body map. 5Patients are instructed to pay attention to what happens within their own bodies as they work on the body maps. They are told to indicate the need for a ‘time out’ if their own bodily responses become too intense or if they feel they are becoming less present in their surroundings (i.e., dissociating). The therapist also encourages this approach by pausing in the process to inquire about current bodily states (such as asking, ‘How are you feeling in your body right now?’ and ‘Do you notice any tension anywhere?’), and to do a scan of the body, further inter- vening with guided grounding or relaxation as necessary. Body mapping is typically done by Morgan and Solomon in a group setting, in which participants are paired. I opted, while exploring this process with patients with PTSD, to work individually. Body mapping begins by tracing an outline of the patient’s body onto heavy paper, cloth, or canvas. The patient is encouraged to respond to a series of prompts, which I modiﬁed from Morgan and Solomon’s additional prompts for use with a population of people suffering from PTSD:

1. How do you feel today?

2. What is a symbol that represents you?

3. Who supports you?

4. How do you see yourself? Draw a self-portrait.

5. Where are some of your power points? Where do you draw strength from?

6. Traumatic experiences can be felt in the body. Where do you feel what you have been through? How does your body remember? Consider your face, inside your head, on your skin, under your skin, your chest (lungs and heart), your stomach and gut, your muscles, your pelvis, your arms and hands, your legs and feet.

5 Grounding techniques help the individual focus on the here-and-now rather than on the traumatic past. A primary vehicle for this focus is awareness of sensory input. For more information on grounding techniques, a good resource is Marsha Linehan’s Skills Training Manual.

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7. What happens to your body when you blank out, when you lose awareness (dissociate)? What happens to your mind?

8. What techniques do you use to remind your body that you are in the present, not in the past time of the traumatic event(s)?

9. Do you take any medications? What do they look like on/in your body? What side effects have you experienced?

10. What is a personal slogan that you live by?

11. What do you see for your future? Is there anything you are doing now you would like not to be doing? Is there anything you are not doing you would like to work toward doing?

These prompts can be responded to on the body tracing with words, symbols, and any other marking, creating a ‘map’ of experience within the body. This process of developing the map in response to the prompts occurs over three to four psychotherapy sessions. It is important to note that patients regulate their own pace and depth of response to the prompts. The process concludes with giving patients the opportunity to narrate their body maps to the therapist, translating the maps into words, and into the process of guiding others to navigate their maps and sharing the experiences of the body.

MR

M ’ S

BODY

MAP

In this adaptation, I accompanied mapping with psycho-education about PTSD – work on bodily techniques such as relaxation, breathing, and tech- niques to address dissociation. Over the course of four sessions, Mr M worked on ﬁlling in his map. When he became overwhelmed or appeared blocked and did little in response to a prompt, we paused to do grounding or relaxation exercises. Once we reached the end of the prompts, he was invited to ‘tell the story’ of his body map, and of the experiences he had had in his body (see ﬁg. 1). Mr. M’s body map provides an intriguing array of visual symbols in his images, choice of colours, and scale of rep- resentation. There are no doubt forms of art therapy that would make more explicit and proﬁtable use of these symbols, perhaps attempting interpretations and possible readings through questioning and dialogue with the patient, and this may be an avenue for further exploration. Although he was not speciﬁcally asked to comment on details of the drawing or to relay any events of the trauma, he provided a narrative:

I am coming to realize that seeing the death of my girlfriend, even though it happened so long ago, is still affecting my life in ways that were invisible to me. Doing this outline of my body has helped me see all of the hidden ways her murder and my injuries still plague me. What surprised me the most was seeing how everything outside of my body is so bright. I ‘put on a

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Figure 1. Mr M’s body map

happy face’ because I think I have to be strong. I thought I could ﬁght off the memories. I didn’t want people to feel sorry for me. Maybe I was also afraid people would be disgusted or shocked by what happened that night. It really struck me when I was thinking about who was supporting me, all that I could come up with was my own cane. I don’t let people support me; I barely allow myself to use my cane, let alone other people. My cane is a reminder of what I wanted to forget. I get so angry when I feel pain and I

refuse to let it get to me. I don’t want to carry this burden. The pain in my knees, my stomach, my neck, if I focus on it at all I can get sucked right back into that time. I didn’t make that connection before. I didn’t realize that all those places ache when I think about what happened. My slogan is, ‘You

always stand in the same river

...

time does not heal all wounds.’ I think the

person who said ‘You never stand in the same river twice’ never had anything truly awful and unforgettable happen to them. I would like to change my slogan eventually. I would like to have scars instead of open

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wounds. I hope that in the future I can bring some of that brightness inside of me and that I can smile with my own face and with my whole body.

TRACING

BOOKS

An addition to the body map, introduced by Morgan and Solomon, was to have participants create small, page-sized outlines of the body. These were duplicated and collated in books called tracing books, in which participants could keep a daily record of bodily experiences, symptoms, side effects of medication, questions for their health-care providers, and information related to their medications and illness. I also introduced this to the patients with whom I worked, using body maps, focusing on daily sensations and experiences within the body, and encouraging them to represent these as illustrations. The tracings were then brought to our psychotherapy sessions, where the patient was invited to describe the experiences of his or her body

Figure 2. Tracing book 1

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Figure 3. Tracing book 2

in words. In this way, the newly learned skill of describing and labelling somatic and affective experiences was generalized to the everyday and prac- tised as we went along. See ﬁgures 2 and 3 for an example of these tracings.

DISCUSSION

Body mapping appears to have potential as a tool in psychotherapeutic work with people who have experienced psychological trauma, particu- larly in those with alexithymia and/or somatic symptoms. It remains to be articulated just what body mapping is, or what its effective com- ponents are. Certainly it is outside the realm of typical psychiatric prac- tice, though it may help to consider the ways in which body mapping overlaps with typical psychiatric practice. Primarily, body mapping results in a narrative account of experience, in this case of traumatic experience. Where it diverges is in its self-conscious bringing of the

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body into the therapeutic arena. As Antonio Damasio might put it, body mapping harnesses both bottom-up and top-down levels of experience. In so doing, it provides the therapist and patient with a concrete set of tools for referring to the body, hopefully inviting the chance to register and monitor what is unfolding in the body, making that process more self- reﬂexive, and ultimately allowing a locus for intervention into the body’s experiences. Body mapping also differs from traditional therapeutic approaches in working, at least at the outset, with visual images rather than with words. I initially understood body mapping as a bridge to integrating the experi- ences of the body into narrative representation. Such a move from the level of bodily to semantic representation allows patients to gain greater moment-to-moment awareness of what is happening in their bodies and allows a greater integration of all levels of experience. While I con- tinue to see this bridge to narrative representation as key, I think that we require a greater understanding of visual processes themselves – another area that has been grossly under-recognized in psychotherapy and in psychiatry. The analysis of the role of the visual in trauma (and traumatic memory) is an additional point of Leys’s critique of van der Kolk. Leys takes exception to van der Kolk’s assumption that post- traumatic symptoms, such as nightmares and ﬂashbacks, processed at a primary sensory level and unintegrated into semantic or declarative rep- resentations, are veridical or literal replicas or repetitions of the trauma (229). In other words, she objects to the claim that these primarily sensory, typically visual, remnants of the traumatic experience are ‘“etched” or “engraved” on the mind with timeless accuracy’ (239), and ‘dissociated from all verbal-linguistic-semantic representation’ (247), and therefore impervious to symbolization and to other psychological processes of subjective transformation. She cites van der Kolk’s sugges- tion that a ‘painting cure’ might be a useful therapeutic intervention as symptomatic of this assumption, and she decries the suggestion that ‘elements of the paintings produced in this way are literal reproductions of the traumatic events in question’ (249), rather than symbolic forms in their own right. Leys’s is an appropriate caution, and I do not understand the process undergone through body mapping as non-symbolic. Damasio, in his model of consciousness and mind, provides a more nuanced understand- ing of the brain’s use of non-verbal storytelling. He suggests that iconic inner symbolization precedes language in the making of consciousness – that we think ﬁrst in non-verbal narrative forms (184 – 91). I do not know why body mapping seems to evoke elements that verbal narrative alone could not, or why it provides a greater integration of experience into the autobiographical self. Body mapping may be one route towards creat- ing a more coherent and ﬂexible representation of traumatic experience, a

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movement towards controlling and taking ownership of one’s memories, rather than being unsettled and besieged by them. I am also now cautious about privileging the construction of the verbal representation of experi- ence over the visual. The fact that it is necessary to include the visual representations as a partner with the text in this paper is testament to the fact that the verbal narrative does not elide the need for the visual, nor does it fully capture all of the information and complexity of the visual images. Certainly the visual is easier to share with another, a key element of healing in the psychotherapeutic encounter. I suggest that in addition to encouraging the labelling of somatic and affective experiences, and providing a concrete bridge to move somatic experience to the level of semantic, narrative representation, body maps also serve an important interpersonal function – of sharing one’s experi- ences with another person. 6This function was mobilized within Morgan and Solomon’s groups of women living with HIV/AIDS and made pre- viously incommunicable experiences ‘speakable;’ in the process, such communication helped to defeat stigma and its attendant secrecy, shame, and isolation. The same may also be true for people suffering from PTSD, particularly from traumas that are considered shaming and unspeakable. As Mr M said, ‘I was also afraid people would be disgusted or shocked by what happened that night.’ Such expectations can leave people to experience their pain in isolation, without the containing and integrative potential to be realized from communicating experience to another person. As with all psychotherapy, however, body mapping is not always or necessarily a benign process and should be carefully considered as an intervention. One likely reason that bodily based psychotherapies have been slow to develop within psychiatry and other related ﬁelds is that they challenge the long-held tradition of maintaining the therapist’s dis- tance from the patient. They also potentially strain the comfort level of a therapist who is not used to being physically close to patients. Patient–therapist boundaries exist for many theoretical and practical reasons. Body mapping’s very interpersonal nature, while potentially therapeutic, necessitates an awareness of boundaries, particularly in trau- matized people whose sense of interpersonal trust may have been vio- lated. It is important to respect such boundaries and to work with the awareness that all kinds of seemingly benign stimuli can trigger traumatic

6 The importance of the interpersonal in traumatic experience, in its aftermath, and in healing, cannot be overstated. Felman and Laub provided one of the ﬁrst paradigms for understanding the importance of the other, and of witnessing. Early psychoanalytic concepts of transference and of the therapeutic relationship have always implicitly acknowledged the importance of the interpersonal. Recent evidence also suggests that interpersonal psychotherapy, without using exposure methods, can be helpful in the treatment of post-tramatic stress disorder (Bleiberg and Markowitz).

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memories. Another less immediate concern is with the ethics of represen- tation, of creating an object that may then be reiﬁed. The body map should be seen not as a static and lasting memorial to traumatic experience but as a provisional tool to augment reﬂection and communication. This provi- sionality may be somewhat occluded by the great beauty and impressive representational power of the completed maps, whose aesthetic quality often belies the pain of these narratives. We need to be vigilant against being seduced or distracted by the objects and must continue to see them as a means to an end. For this reason, the tracing books may ulti- mately be just as beneﬁcial, without these attendant risks. More obviously provisional and casual, they have a more evident utility, although it is unclear to what extent the life-sized, direct proportions of the larger body map may facilitate accessing bodily experience. Each method should also be more fully investigated beyond the limited methodology of a single case report such as this. The very metaphor of memory (and body) mapping invites us also to think of the traumatized body at the juncture of the psychological and the social. The interior map extends out into social space. What aspects or experiences of the body can be freely expressed in the social realm? Julia Kristeva has written about the ‘self’s clean and proper body’ (71) as the condition for entry into language and thus into the social order. The body’s boundaries are demarcated; nothing is supposed to spill out of the body. If the pre-linguistic, guided by the maternal, allows for ‘corporeal mapping’ (72), the social order and language (the patriarchal) require that the body be abjected, that it be silenced and placed outside of language. This cultural abjection becomes particularly fraught for someone who is traumatized; already victimized and abjected, the traumatized person is further jeopardized by a dysregulated body that cannot be silenced or given meaning. The traumatic sequelae of the body are experiences that our own social systems – in particular medicine and psychiatry – have dif- ﬁculty approaching and containing. Lawrence Kirmayer points to two ways to understand traumatic narrative and memory (the extremes of remembering or forgetting): the ﬁrst is through recourse to a purely psycho-biological mechanism, the other is to understand the role of the social or cultural determinants of what can be remembered or represented. The history of trauma theory demonstrates this socio-political struggle, as Judith Herman, Ian Hacking, Ruth Leys, and many others have docu- mented. In the nineteenth century, with advances such as in locomotion resulting in mass casualties, new categories were required to describe and categorize traumatic injuries. The impact of such traumatic events was measured by the resultant damage to the body. In the late nineteenth century there was ﬁnally an acknowledgement that trauma could happen to the mind as well as to the body (Harrington). This transfer, the meta- phor that the mind could be injured in the same way as the body, may

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unwittingly, along with other social forces, have shifted attention away from the body. Having said that, psychological trauma is one ﬁeld within psychiatry in which psychotherapeutic approaches to the body are emerging and challenging these ideas. Working with body mapping unmasks a whole series of dialectics that structure our ways of engaging with patients and their experiences. We need to dislodge simplistic dua- lities such as mind versus body, representation versus reality, and language (narrative) versus image. Psychotherapy is an important arena for remembering in our culture. If, in this arena of remembering, the body cannot be allowed or encouraged to add to the narrative of experi- ence or to add its own form of narrative, to be brought into autobiographi- cal memory, then traumatized subjects and their experiences are at risk of being left outside of meaning, outside of making sense within the very ﬁeld that promises to heal them.